The internet's only blog on Health Insurance

April 30, 2007

Pre-existing conditions should not disqualify health insurance

Each individual possesses genetic markers and medical technology has advanced to the level that the human genome can be mapped to specifically predict a person's predisposition to disease.

An unborn child can be tested by a trained physician to determine susceptibility to certain diseases - such as cancer, diabetes or Alzheimer's - decades before they're diagnosed. This information can lead to early treatment and perhaps even cures, but the fear that it could be used to deny people health insurance and employment opportunities accompanies it.

That trepidation is one step closer to being calmed with the U.S. House passage of HR 493 - the Genetic Information Nondiscrimination Act. The Senate is expected to follow suit making it illegal for health insurance companies to deny people coverage because of their genetic make-up and for employers refusing to hire people for that same reason.

While I want to shout "Hooray" and celebrate the legislation that basically tells these companies it is none of their business as to what health condition a person could likely develop, it does nothing to solve the discrimination occurring now with "pre-existing conditions."

My 2-year-old son was diagnosed with a tectal plate brain tumor, located at the brain stem, that caused hydrocephalus when he was 8 months old. It was determined by his pediatric neurosurgeon to be congenital. Fortunately, my husband and I were able to insure him the day he was born from an employee contribution plan through my spouse's employer. This plan covers our entire family. Thinking ahead, we decided to look into acquiring affordable health insurance for our son after my husband's retirement, which is in about 10 years. Guess what? No one will insure our little guy because he has a "pre-existing condition."

The option we were told repeatedly by insurance companies, which would be a sure way to get our son insured, was to become destitute, liquidating all our assets, to qualify for governmental assistance through Medicaid. It was offensive every time to be told discreetly in all its political correctness that the health care system does not encourage people to be productive.

Quite the contrary, even though knowledge and treatment are leading to better health for people with conditions like my son - which were less than 20 years ago debilitating and deadly - because an innate ailment is possessed, those people are automatically disqualified from insurance that would help provide health care services and medications that could prolong life and even enable those people to be positive contributors to society.

April 28, 2007

Group begins health insurance study

A task force studying health care coverage in the state will find out first who doesn’t have medical insurance and why.

A polling firm will update studies on uninsured South Dakotans done in 2001 and 2004, said Kevin Forsch, a governor’s staff member who is coordinating the project.

The goal, Forsch said, is to answer the questions, “Who are the uninsured? Why are they uninsured? How long have they been uninsured?”

A 2001 study concluded that 8.1 percent of South Dakota residents lacked insurance. A 2004 update put the figure at 8.5 percent.

The so-called Zaniya Task Force was created by the 2007 Legislature after bills died that would have required health care coverage for all residents. Many lawmakers and Gov. Mike Rounds said that was premature without current data on the number of people without insurance and the reasons they lack coverage.

April 25, 2007

What is a PPO or Point of Provider Oganization

A Preferred Provider Organization is a form of managed care closest to an indemnity plan. A PPO negotiates arrangements with doctors, hospitals and other providers who accept lower fees from the insurer for their services. As a result, your cost-sharing will be lower than if you go outside the network of providers.

If you go to a doctor within the PPO network, you will pay a copayment (a set amount you pay for certain services -- say $20 for a doctor or $10 insurer may reimburse you for 90 percent of the cost if you go to a provider within the network. If you choose to go a provider out of the network, the insurer might only reimburse you for, say, 70 percent of the cost.

In addition, with an out-of-network provider, you must pay the difference between what the provider charges and what the plan pays.

Another characteristic of PPOs is the ability to make self-referrals. In essence, plan members can refer themselves to doctors of their choice, including specialists, inside and outside the network. However, as described above, plan members may incur additional charges for using out-of-network providers.

April 23, 2007

Health care is a business...or should be

Ultimately all health care is paid for by business activity. Business provides the wages, the return on investment, the insurance, the taxes that pay directly for health care, and the insurance and taxes that fund government programs. When the government manages to provide services at all, it can give you nothing that it does not take from you or others, or from your employer and other employers. The total added value the government creates for your benefit is nothing.

The government now uses your money to pay for 50 percent of health care. That is up from less than 10 percent, forty years ago. The increase in health care costs that has accompanied this process is largely caused by government...the actual origin of the "health care crisis," discovered and proclaimed by Richard Nixon and Edward Kennedy in 1971. Their proposed solution was more government. They got it.

The "crisis" was created by government, not just through its own reckless spending, but through the consequent destruction of much of the free market.

In a free market, if you did not have much to spend on insurance premiums, you could buy a policy that simply covers you for a major illness or a severe injury. Many people worry about the financial ruin that might result from such misfortune and want coverage only for that. They are willing to take their own risk for routine medical expenses if they have reasonable coverage for emergencies.

Such policies are often forbidden by state governments. In California, for example, such policies are not available. Legislators and regulators have imposed 49 specific coverage requirements on all insurance companies. Many states have such requirements. It does not matter if you do not want coverage for chiropractic, or in vitro fertilization, or electronic shock or hypnotherapy for mental illness...you may still have to pay for it. That is, providers in the insurance business are not allowed to offer a policy that you might want and that they would like to offer...they are forbidden. If those restrictions drive the cost of insurance up to more than you can pay, you can thank the government. Insurance policies will get even more expensive in California if the recent proposal of the Governor to require coverage of such "wellness" care as gym and Weight Watcher memberships becomes law.

There are those in the insurance business in other states who could help you with a policy that meets your needs at a cost you can afford. But they cannot, because policies from out-of-state providers are outlawed by your state government. When bills were proposed in Congress to allow for a national market for health insurance, insurance commissioners and other state officials around the country rallied in opposition, because consumers in each state would lose the protection of their state's regulations. It appears that state officials are horrified at that thought of leaving the citizens of their own states to the tender mercy of the regulators in other states.

But relief is on the way. Massachusetts passed a law that you must buy insurance with these expensive regulatory burdens or pay a fine. Isn't that helpful? California now wants to do the same thing and also wants all physicians and hospitals to pay a new tax...not on net income but on gross revenues. That will increase their billings and your insurance premiums further. But who cares?...you would have to buy the insurance, and imposing coverage on everyone is all that matters.

April 20, 2007

Health Insurance: Women have trouble affording care needed

As Cover the Uninsured Week approaches, a new Commonwealth Fund report by researchers at the National Women’s Law Center finds that even women with health insurance coverage are more likely than insured men to go without needed health care because of costs. Also, a higher percentage of women than men struggle with medical bills.

The report, Women and Health Coverage: The Affordability Gap, by Elizabeth M. Patchias and Judith G. Waxman of the National Women’s Law Center finds that women are at a disadvantage because they have greater health care needs and lower incomes than men. More specifically, the report finds that 38% of women are struggling with medical bills compared with 29% of men. And, the high cost of health care services and premiums is forcing many women, even women with health insurance, to go without needed care. In fact, 33% of insured women and 68% of uninsured women don’t get the health care they need because they can’t afford it. In contrast, 23% of insured and 49% of uninsured men are avoiding care because of cost. Further, 16% of women are underinsured, meaning they have high out-of-pocket costs compared to their income, while only 9% of men are underinsured.

"Women are more likely than men to go without needed health care services because of costs, yet they still have higher out-of-pocket expenses. This disparity exists for both insured and uninsured women," said Waxman, vice president for Health and Reproductive Rights at the National Women’s Law Center. "As policymakers and advocates explore how to expand and improve health coverage, they should ensure that any proposal provides comprehensive benefits and low cost-sharing."

Other factors contribute to this gender gap in health care coverage and access: women are slightly more likely than men to purchase coverage in the individual insurance market which is often more expensive and less comprehensive than employer coverage. Women are also more likely than men to take prescription drugs.

"These findings show that comprehensive health care coverage that doesn’t require high out-of-pocket costs is vital to ensuring that women get the care they need to be healthy," said Sara Collins, assistant vice president for the Program on the Future of Health Insurance at The Commonwealth Fund. "As policymakers consider health care reform initiatives, they should consider plan designs that will result in meaningful, affordable, and equitable access to health care for everyone."

April 18, 2007

What is an HMO?

This is a broad term that, in general, refers to any organized plan other than a traditional health insurance company that provides for your health care. Some plans are very tightly structured so that all care is provided by the HMO's employees in the HMO's hospitals or clinics, while other plans are cooperative agreements among independent doctors, hospitals and other health care providers.